Posted tagged ‘food’

Dr. Roy, do you have any advice about a preschooler who wants to be a vegetarian? A few days ago at a family party an older cousin decided to tell my four-year-old aspiring veterinarian, who loves animals so much she sobs if she accidentally steps on an ant, what her hamburger was made out of. She…did not react well to the information, and has since steadfastly refused to eat any type of meat. Thankfully she’s too young to know that veganism is a thing so she’ll still eat dairy products and eggs and such, just not meat, which I’ve always heard is a pretty important part of a growing child’s diet. Is it safe for a kid so young to *never* have meat? Should I get her on some special vitamins or supplements or make sure she eats plenty of certain other foods to make up for it? Or do I just need to put my foot down and insist that she eats whatever I make? All of the advice I’ve found so far basically boils down to that, but it seems like that would be so traumatizing and send her the message that I don’t care about how she feels or what she values. I just want to keep her healthy, physically AND emotionally, but I don’t know what to do!

Lisa: “What’s the difference between this lamb and the one that kissed me?”

Bart: “This one spent two hours in the broiler!” [takes a big bite]

From a nutritional point of view, meat is a great source of easily-digested protein and bioavailable iron. But, really, very few American kids have a problem with not getting enough protein in their diet. All dairy products are complete proteins, as are eggs and peanut butter and delicious bacon. I mean tofu.

Homer: “Lisa, honey, are you saying you’re never going to eat any animal again? What about bacon?”

Lisa: “No.”

Homer: “Ham?”

Lisa: “No.”

Homer: “Pork chops?”

Lisa: “Dad! Those all come from the same animal!”

Homer: [chuckling] “Yeah, right, Lisa. A wonderful, magical animal.”

Iron, though—iron might be another story. Iron can be found in some vegetables, especially those dark leafy green ones that Lisa loves, and beans and grains. But that kind, called non-heme iron, isn’t easily absorbed. The heme iron found in meat and seafood really does get into your body better. Absorption of non-heme iron can be increased by consuming foods with vitamin C (like citrus fruits), eating your non-heme iron with a little meat (not Lisa’s first choice), or cooking with a cast-iron pot. If none of that is practical, it’s easy enough to get an iron supplement to replace the iron in meat.

[Doris picks up a hot dog, shakes the wiener out, and slaps the bun down on Lisa’s tray]

Doris: “Yum. It’s rich in bunly goodness.”

Lisa: [dryly] “Do you remember when you lost your passion for this work?”

I’m assuming, here, that the child is willing to continue eating dairy products—without those, it’s difficult to get enough calcium and vitamin D. I think a family can easily follow a lacto-ovo vegetarian diet (including dairy and eggs) without much worry, and in fact such a diet is almost certainly more healthful than that of many families. But strict veganism, with no eggs and no dairy, is tricky, especially with younger children. I suggest any family who’s raising vegan kids spend some face-to-face time with a registered dietician (NOT a “nutritionist”! Don’t get me started on nutritionists.) That way they can learn what they need to know to ensure an adequate diet and correct use of supplements. It can be done, but it requires some work and planning.

Paul McCartney: “Linda and I both feel strongly about animal rights. In fact, if you play ‘Maybe I’m Amazed’ backwards, you’ll hear a recipe for a really ripping lentil soup.”

Lisa: “When will all those fools learn that you can be perfectly healthy simply eating vegetables, fruits, grains and cheese?”

Apu: “Oh, cheese!”

Lisa: “You don’t eat cheese, Apu?”

Apu: “No, I don’t eat any food that comes from an animal.”

Lisa: “Oh, then you must think I’m a monster!”

Apu: “Yes, indeed, I do think that.”

Leslie asked if she should just put her foot down, to force her daughter to eat meat. I don’t think that’s the way to go. I can respect her daughter’s wish to not harm animals, and she can have a perfectly healthful diet that fits her own moral philosophy. Yes, even four year olds can and should have a sense of right and wrong, and I’m not so sure we meat eaters are in fact morally superior to a vegetarian preschooler. Or Lisa Simpson.

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As we’ve seen, the problem isn’t the picky eating, per se. Kids are getting enough calories, and they’re certainly growing big enough. Even the skinniest kids in today’s world are far healthier and have far better nutrition than most of the kids from previous generations. And I certainly haven’t seen health problems in the slender kids in my practice. What I see very commonly, though, are health problems from overweight: diabetes, high blood pressure, depression, and social isolation.

So, no matter what else, the first principle of healthy family eating should be to help foster a child’s own normal sense of appetite and hunger. This is The Rule of mealtimes. It’s The Truth, and The One Ring to rule them all:

If you’re hungry, eat.

If you’re not hungry, don’t eat.

(OK, so it’s two rules. Close enough.)

Humans have a built-in mechanism to control food intake, and it works well at every age. It’s called “hunger.” Often, though, we unintentionally raise our kids in ways that teach them to ignore their appetite cues and eat for all sorts of other reasons.

Think about it. In American culture we don’t just eat when we’re hungry. We eat to celebrate. We eat when we watch a movie, we eat when we’re on the phone. We eat when we’re upset, and we eat when we’re bored. We eat when we’re happy and we eat when we’re sad. Often, we eat because others encourage us to eat. Family and friends ply us with food, and mom loads up our plate. We also have to contend with an ever-present marketing effort to get us to eat even more. Most two-year-olds already recognize “The Golden Arches”, and TV and computer banner ads are a near-constant barrage encouraging us to eat. And eat. And eat.

In a way, I’m surprised obesity isn’t more common.

Let’s not make matters worse. From a very early age, encourage your children to manage their own appetite. This means that a nine-month-old who becomes less interested in nursing should be allowed to wean. And a two-year-old who wants to explore instead of cleaning his plate should be allowed to leave the table. When a child doesn’t have an appetite to eat more, do not try to trick or fool or guilt or otherwise “get him” to continue eating. Lacking hunger means the child has eaten enough. Meals shouldn’t end when mom or dad thinks Junior has had enough; meals should end when Junior thinks he’s had enough.

In fact, from The Rule flows two other rules which guide the roles of children and parents at mealtimes:

Parents should offer healthful foods in an appropriate manner.

Children decide which foods to eat, and how much to eat.

Simple! Or at least simple to say, and simple to understand. That doesn’t necessarily mean it’s always easy to do!

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I’m writing from my hotel in Washington, DC at the American Academy of Pediatrics annual national convention. It’s definitely pediatrics—some of the exhibitors were handing out lollipops today, and one even brought along a puppy to play with!

One of the best talks I heard today was from an allergist, reviewing the science behind allergy testing, when to do it, what it means, etc. But the biggest eye-opener for me occurred during the questions afterwards. I’m embarrassed to say that it’s obvious that many pediatricians haven’t got a clue about how to diagnose allergies. And if the peds aren’t getting it right, where does that leave the parents? So I’m going to skip right past your pediatrician, and today reveal…the deep dark insider story. It’s time for a top ten list, the top ten myths about allergy that pediatricians are getting wrong.

#1 Food allergies are common

Many people think they’re allergic to foods, but rigorous studies using the best, most reliable diagnostic tools find food allergies to be present in about 2-8% of the population. Most of these reactions are mild. True, life-threatening food allergies are quite rare—in the United States, about 150 people die each year from food allergies, which is only a little higher than the number of people struck by lighting.

#2 Most reactions to food are allergies

An allergy refers to a specific kind of reaction, most commonly hives or wheezing. Other, more common reactions include lactose intolerance (an inability to digest milk sugar, leading to abdominal cramps and diarrhea) and gastroesophageal reflux related to spicy or acidic foods. The distinction is important because rare, very serious allergic reactions can occur. If the reaction was not allergic in nature, it will not possibly be life-threatening if exposure occurs again.

#3 Most reactions to medicines are allergies

The most common adverse reaction to a medication is a rash, but these are usually not caused by allergy (the only common truly allergic rash is hives, which are raised, itchy areas that move about the body.) Most people labeled as “allergic” to penicillin are not in fact allergic, and can safely use this medication. Only a careful history and exam can determine this—there is no accurate test to confirm or refute true drug allergies. If you or your child is thought of as drug allergic, review the exact circumstances with your physician to see if it is a good idea to try the medication again (do NOT do this on your own!)

#4 People who are allergic to a medicine should never take it again

Certainly, if a life-threatening reaction occurred you need to be very careful. And be much, much more wary of medications given as a shot or intravenously (I’m not sure anyone has ever died as a result of an allergic reaction to oral penicillin.) But unless the reaction was a true allergic reaction, usually manifested by hives or wheezing, a medication can usually be given safely in the future (again, do NOT do this on your own!)

#5 If you’re allergic, but can tolerate “a little bit” of the allergic trigger, it’s good to keep taking that little bit

This one was new to me, but someone brought it up. The idea is that there may be some people who seem to be able to tolerate “a little bit” of their trigger, let’s say a little cheese, but has a belly ache if they consume a lot of milk. So maybe it’s OK for them to take that little bit.

No! First, you have to ask, is the patient really allergic? In my cheese example, the patient probably has lactose intolerance, not an allergy—so it’s fine to take some dairy, if it doesn’t hurt.

But in a truly allergic individual—one with true allergic symptoms—even consuming a little bit of the trigger is going to perpetuate the allergy and make it less likely to outgrow it. So if your child is really allergic, don’t cheat!

#6 People with any history of egg allergy shouldn’t get a flu shot

There is a tiny amount of egg protein left over from the manufacturing process of making influenza vaccines. If your child has a severe egg allergy, flu vaccines cannot be given; but for children with far-more-common mild reactions, flu vaccinations are safe and a good idea. If in doubt, egg allergy testing can be done, or the flu shot can be given at the allergist’s office.

#7 People with egg allergy shouldn’t get an MMR vaccine

This just isn’t true. It’s a myth. MMRs can safely be given to anyone with egg allergies.

#8 Allergy testing can tell you if a child is allergic to something

Hoo boy, pediatricians seem to miss this one! The way to know if a person is allergic is entirely in the history: do symptoms of allergy occur upon exposure? If they do, that’s allergy; if they don’t, that is not allergy. If the history is clear, the diagnosis is nailed, done, confirmed, and set. No tests are needed; in fact, tests are quite likely to confuse the picture.

Allergy tests are for when the history is not clear, to help separate exposures that are “likely” from “less likely”, so that further history can be explored and attempts at avoidance attempted to see what the response is. Allergy testing, either with blood tests or skin testing, is far too inaccurate to be used in any other way.

Be especially wary of web-based labs that promise extensive allergy testing to investigate vague symptoms like weight gain, abdominal pain, low energy, fatigue, and behavior problems. These symptoms are not caused by allergy, though fraudulent testing will inevitably lead to false positives and incitements to purchase detoxifying supplements. This is quackery, and expensive quackery at that. Stay away!

#9 Hives are usually caused by allergies to foods

In adults, this might be true; but in kids, hives are more often triggered by minor infections than by food exposures. Sure, if there are hives you ought to think about potential new foods, and if there is a correlation you ought to look into that. But in the majority of cases in pediatrics, isolated or even recurrent episodes of hives are not necessarily from food allergies.

#10 Specific allergies run in families

“Don’t give him penicillin! Mom’s allergic!” While the predisposition to allergies, asthma, and hay fever run in families, it isn’t to the same specific trigger. Junior has a mom with shrimp allergies? That means that he might more likely have food allergies of his own, but not more likely to shrimp than to peanut or egg or anything else. Same for medication allergies.

If your physician is telling you myths from the above list, it’s time to ask for a referral to an allergist to get the best information. If it’s an allergist tell you one of these myths, well, I’m stumped.

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Poornima asked, “Are there any tests that are conducted to confirm that a child has milk allergy? My child is 4 and is on soy based milk (she was on cow’s milk for almost a year). Even now she eats cheese, pizza etc. cannot eat yogurt. She did not break into hives or anything like that. May be a test could prove that she is allergic to milk protein.”

I know when people ask about tests they mean something fancy and mysterious: a blood test, or a skin-test done at the allergist’s office. But in reality, the “gold standard” best test there is for allergy is called a “double blind placebo controlled trial.” That is, you package up some of the potential allergen (in this case, milk) in such a way that the child and the parents don’t know it’s there. Then give some to the child. If the allergic-type reaction occurs when the child gets the genuine milk, but not when given a milk-substitute, than there is a milk allergy. No other tests are necessary.

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“My daughter who is one does not seem interested in feeding herself. Whenever I sit down and eat with her – I try to guide her fingers into her mouth while she is holding a piece of food. She starts crying hysterically. After 30 min of sitting there and playing with her food, I end up feeding her jarred baby food. She has even gone as far as handing the finger foods back to me and then opening her mouth to show me that she wants me to put it in her mouth. The same goes for sippy cup vs. bottle.”

You’ve got some ingrained habits that may not be quickly fixable, but I’ll answer the question in a general way that should help you and other families. You should talk with your pediatrician for more specific advice, and consider asking for a referral to a “feeding center” which works with children to establish better eating and feeding routines. I don’t know if your child is unable to feed herself, or unwilling. You didn’t mention any sort of motor delay or oral-motor problem, so I suspect it is more a matter of habit. However, you two are certainly locked in a battle of wills at this point, and you may need more hands-on expertise to work your way out of it.

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DMT asked, “My daughter is almost 2 and has had several bouts of hives. The first bout or two lasted only a day or two. The third lasted for 8 days, and the fourth for 10 days. They come and go in patches in the matter of an hour or two, and I have been told numerous times that it is a virus. We have been to an allergist, and he does not believe it is due to allergies, either. She has been on Zyrtec for about 1 month. One day, I forgot to give it to her in the am, and she had 2 little hives. Today, she spit the Zyrtec out (and I did not attempt to give her more), and she woke up from her nap with 4 or 5 huge hives. This is leading me to believe it is allergy based. Any ideas?”

This comes up frequently, and I’m glad you asked about it. Many doctors are getting this wrong, and it’s causing more grief for families than the hives themselves.

First: If your child has hives accompanied by difficulty breathing, unconsciousness, or swelling of the lips, throat, or tongue, call emergency services (911) right away. Though most hives are not serious and do not lead to a more severe reaction, you need to react quickly to any reaction that includes difficulty breathing or a loss of consciousness. (more…)

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Katie posted: “My daughter’s 10 months old. She takes 4 bottles a day, about 20oz. I want to ease into the 1 year – weaning – thing. What is the minimum amount of formula I should give her? Can I go ahead and supplement with milk, or is it best to wait until she is 1 year old?”

By 10 months, your daughter should be eating solids at least three times a day, and solid meals should include a good variety of ordinary table foods that you share with her at family meals together. This can include almost any sorts of foods, except nuts, peanuts, and raw honey. All of these foods ought to be soft enough for her to “gum them.” Good examples are noodles, well-cooked veggies, beans, crumbly meat, cottage cheese—almost anything can be ripped apart so it’s soft enough for a 10 month old.(more…)

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